Block 13 H + S Flashcards
What percentage of deaths does CHD cause in the UK?
29% men, 28% women
Why are the death rates falling from CHD?
-Risk factors improved - Fewer smokers, cholesterol better controlled, HTN controlled
- Treatments - Medical interventions improved for various cardiac conditions
What is the effect of health inequalities on CHD?
Lower social class at higher risk - Health behaviours
What are the non-modifiable risk factors for CHD?
-Increased age
- Gender - Before the age of 60 men are at greater risk than women
- Family history - Risk may increase if close blood relatives had early heart disease
- Race - High rate for african americans and asians
What are the modifiable risk factors for CHD?
-Elevated blood cholesterol - High LDL, low HDL - High blood pressure - Diabetes - Smoking - Obesity - Inactivity - Excessive alcohol -Excessive stress
What is risk?
The probability of an event in a given time period
What is the equation for risk ratio?
Risk ratio = Riskexposed/Riskunexposed
What is the equation for risk difference?
Risk difference = Riskexposed - Riskunexposed
What is odds ratio and what is the equation?
Probability of disease occurring in exposed group/probability of disease occuring in unexposed group
What is population attributable risk?
The risk of disease will increase as the exposure prevalence or relative risk increases
What is the leading cause for cancer mortality?
Lung cancer
What are the main risk factors associated with lung cancer?
-Smoking - Radon - Asbestos - Environmental tobacco exposure -Genetics -Other lung diseases - Prior radiation in chest area
What is the second leading cause of lung cancer after smoking?
Radon
What are the different types of lung cancer?
-Small cell (13%)
- Non-small cell (87%) - Adenocarcinoma (>40%), squamous cell carcinoma (20%),
large cell carcinoma (2%)
-Mesotheloma
How many people in the world are infected with TB?
1/3 of world population
How many deaths per year does TB cause (million)?
3 million
What are the factors associated with recent increases in the prevalence of TB?
- Urban homelessness
- IV drug use
- Growing neglect of TB control programs
- AIDS epidemic
What time of the year does TB incidence peak?
Spring/summer
What can be done to address rising rates of TB?
-Put more people on ART
- New vaccine
- Improved drugs
- Diagnose better
What is the prevention paradox?
A preventive measure that brings large benefits to the community offers little to each participating individual
What are the pros and cons of ‘high risk’ approaches to health promotion?
Pros:
- Appropriate to individual
- Motivated subject
- Motivated clinician
- Cost-effective resource use
- Benefit for risk is high
Cons:
- Screening is difficult
- Palliative and temporary
- Limited potential as not many people
- Labelling
What are the pros and cons of ‘population’ approaches to health promotion?
Pros:
- Large potential as targeting many people
Cons:
- Population paradox - Small perceived individual benefit
- Poor motivation can cause compliance issues
- Benefit for risk is low
What are some examples of occupational lung diseases?
- Occupational asthma
- COPD
- Pneumoconiosis
- Toxic pneumonitis
- Hypersensitivity pneumonitis
- Benign pleural disease
- Infections including TB
- Malignancy of lung and pleura
How has occupational health risks changed over time?
- E.g. from mid 20th century with coal mining etc - Better environmental control and health and safety
- Depends on health of the population and local industry
- Diagnosis of occupational lung diseases (e.g. occupational asthma) has improved
- Biological factors - Predisposing/protective factors
What is occupational asthma?
Like other types of asthma, it is characterised by airway inflammation, reversible airways obstruction, and bronchospasm, but it is caused by something in the workplace environment
What are some of the causes of occupational asthma?
Bakers, welders, paint sprayers, laboratory workers
What history would you expect from a patient with occupational asthma?
-Symptoms worse at work and better away from work e.g. weekends or holidays
- Peak flow falls at work and improves away from work
Give some occupational causes of COPD?
Coal mining, agriculture, construction, dock workers, brick making
What is pneumoconiosis?
Occupational restrictive lung disease caused by inhalation of dust (coal dust, silica, asbestos)
What is simple coal workers pneumoconiosis?
- After around 10 years coal mining, small nodules are present
- Shouldn’t cause major impairment in lung function
- Some coal workers have symptoms of chronic bronchitis (cough)
What are possible complications with coal workers pneumoconiosis?
Occurs in coal workers especially if the coal they work with is heavily contaminated with silicates
Very serious - Scarred, fibrotic lung distorts the remaining lung (gross obstruction and restriction)
What is silicosis?
- Occupational lung disease caused by inhalation of crystalline silica dust, and is marked by inflammation and scarring in the form of nodular lesions in the upper lobes of the lung.
- It is a type of pneumoconiosis.
What is siderosis?
- Deposition of iron in tissue
- Iron has no effect on lungs - No associated fibrosis or narrowed airways
What is acute pneumonitis?
- Acute inhalation of a substance that causes symptoms immediately
- Can be caused by - Chlorine, ammonia, organic chemicals, metallic compounds
- Form of acute respiratory distress syndrome
What is hypersensitive pneumonitis?
- Type 3 hypersensitive reaction (immune complex deposition)
- It is an inflammation of the alveoli within the lung caused by hypersensitivity to inhaled organic dust
What are some causes of hypersensitive pneumonitis?
-Bird fancier’s lung - Due to feathers and bird droppings
- Farmer’s lung - Due to mouldy hay (moulds and bacteria)
- Metalworking fluids HP - Due to mist from metalworking fluids (non-TB
mycobacterium)
What percentage of lung cancers in men are related to occupation?
10%
What is asbestos?
- Used a lot in the 1950s-60s as a building material - Fire retardant and could be used as cement
- In the 1960s it was found to cause malignant mesothelioma (pleural tumour) - Only a small amount of asbestos was found to cause this
What are the two types of asbestos fibres?
- Serpentine - Curly, white asbestos (relatively harmless), cleared with mucociliary escalator
- Amphiboles - Short, sharp, blue/brown asbestos (have malignant potential)
What is mesothelioma?
-Cancer of the mesothelium almost invariably caused by occupational exposure to asbestos
- Latency period of around 40 years
Where are claims submitted for compensation for occupational illness in the UK?
Disability Benefits Centre of Benefits Agency (DSS)
What is decision analysis?
Systematic and quantitative way of making healthcare decisions e.g. when presented with two options
What does decision analysis assume?
-Decision process is logical and rational
- A rational decision maker will choose the option to maximise utility (the desirability
or value attached to a decision outcome)
What are the stages in decision analysis?
- Structure the problem as a decision tree - Identifying choice, information (what is and is not known) and preferences
- Assess the probability (chance) of every choice branch
- Assess (numerically) the utility of every outcome
- Identify the option that maximises expected utility
- (Possibly) Conduct a sensitive analysis to explore effect of varying judgements
How do squares and circles mean on decision trees?
- Square node - Indicated decision, represents choice between actions
- Circle node - Indicated chance (probability), represents uncertainty, potential outcomes of each decision
How do you calculate expected utility?
Expected utility = utility value x probability
- (0.1x0.35)+(0.5x0.65)=0.36
- (0.36x0.05)+(0.8x0.95)=0.78
- (0.78x0.092)+(0.97x0.908)=0.96
What is sensitive analysis?
Sensitive analysis explores what would happen if the probabilities or utility values were slightly different to the ones you are using - Calculate effect of uncertainty on decision
What are preference sensitive and probability sensitive decisions?
- Preference sensitive - The person might feel strongly about the side effects of the treatment
- Probability sensitive - Sensitive to changes in the chance of different outcomes
What are the benefits of using decision analysis to make decisions?
-Makes all assumptions in a decision explicit
- Allows examination of the process of making a decision
- Integrates research evidence into the decision process
- Insight gained during process may be more important than the generated numbers
- Can be used for individual decisions, population level decisions and for cost-
effectiveness analysis
What are the negatives of using decision analysis to make decisions?
Probability estimates:
- Required data sets to estimate probability may not exist
- Subjective probability estimates are subject to bias
Utility measures:
- Individual may be asked to rate a state of health they have not experienced
- Different techniques will result in different numbers
- Subject to presentation framing effects e.g. survival/death
- The approach is reductionist
What is the ICF model of disability?
Functioning and disability are multi-dimensional concepts relating to:
- Body functions and structures - Physiological functions and anatomical parts
of body, including cardiac and respiratory systems
-Activities
-Participation of people in life
- Environmental factors
What is palliative care?
-Active holistic care of patients with advanced progressive illness
- It aims to treat or manage pain and other physical symptoms and will also help with
any psychological, social, or spiritual needs
What are the goals of palliative care?
-Improves quality of life
- Provides relief from pain and other distressing symptoms
- Supports life and regards death as a normal process
- Doesn’t quicken or postpone death
- Combines psychological and spiritual aspects of care
- Offers a support system to help people live as actively as possible until death
- Offers a support system to help the family cope during a person’s illness and in
bereavement
- Uses an MDT approach to address the needs of the person who is ill and their
families
Who is general palliative care given to?
Core aspect of care for all patients and their families with advanced disease by all health professionals
Who is specialised palliative care for?
Patients (and carers) with unresolved symptoms and complex psychosocial issues, with complex end-of-life and bereavement issues
Who provides specialised palliative care?
- NHS - Community/hospital clinical nurse specialist, some consultants, some in- patient units, macmillan
- Voluntary - Hospice services, in-patient beds, independent charities (marie curie, sue ryder), macmillan
What is end of life care?
- Branch of palliative care - Caring for people who are nearing the end of the life
- ‘End of life care pathway’ - Last 48 hours of life
What are some challenges for the future of palliative care?
-Inequality of service provision and standards
- Funding
-Training, recruitment and retention
-Maintaining a sense of humanity and compassion - Due to increasing technologies
and treatment options for management of disease
What is ‘total pain’?
Recognises pain as being physical, psychological, social and spiritual
What are the different types of nurses involved in palliative care?
- District nurse - Primary health care team, community based, generic palliative care skills, ‘hands on’ nursing skills
- Practice nurse - Primary health care team, practice based, generic palliative care skills, ‘hands on’
- Marie curie nurse - Community based, arranged by district nurse, specialist palliative care skills, ‘hands on’
- Macmillan nurse - Community or hospital based, specialist palliative care, advice, support, resource
Where is the preferred place of death?
Most people wish to die at home
Few people wish to die in hospital
Most die in hospital
Hard to plan because you don’t know when it will happen
What percentage of admission notes document the CPR decisions?
10%
What percentage of in-hospital CPR is not appropriate?
40-50%
What are Bowlby’s 4 stages of grief?
-Numbness
- Yearning/pining and anger
- Disorganisation and despair -Reorganisation
What are the symptoms of grief?
- Sadness, anger, guilt, anxiety, loneliness, fatigue, helplessness, shock, yearning, numbness
- Somatic sensations - Stomach, chest, throat, sensitivity to noise, depersonalisation, breathlessness, muscle weakness, lack of energy, dry mouth
- Concentration impairment, preoccupation with the deceased, hallucinations, disbelief
- Sleep and appetite disturbance, absent-mindedness, social withdrawal, dreams of deceased, avoidance of reminders, searching and calling out, sighing, overactivity, crying
What is Worden’s tasks of mourning?
- Accepting the reality of the loss e.g. come to terms with the person being ‘gone’
- Work through the pain of grief
- Adjust to an environment in which the deceased is missing
- Emotionally relocate the deceased and move on with life
What factors affect the severity of grief?
-Closeness of relationship - Meaningfulness of relationship - Nature of relationship prior to death - Expectedness and manner of death - Age and developmental stage of griever - Social support
What is spirituality?
Umbrella term that includes religious/faith frameworks, but it also includes the meaning of life, purpose, sense of personhood.
How can religious beliefs impact on bereavement?
-Belief in an afterlife - The continuing existence of the loved one and possibility of meeting up again
-Continued attachment - Prayer as means of continuing connection with the deceased
- Defence against fear of personal death/extinction
- Religious funeral rituals that aid and progress the grief process
- Religious funeral rituals that recruit social support
What is pathological grief?
-Extended grief reactions - Getting stuck in one of the phases (normally each phase is about 6 months)
- Can be in denial for an extended period of time - Exhibit mummification (not changing things in dead persons room for example)
-Major depressive disorders >2 months after loss
What is the myth of the neutral therapist?
- Idea that psychotherapists will ‘leak’ their personal views regardless of their intention
- This will come across in their questioning/direction of questioning
